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100 Cards in this Set
- Front
- Back
assess
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to systematically and continuously collect, validate, and communicate patient data
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concept mapping
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instructional strategy that requires learners to identify, display and link key concepts
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critical thinking
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thought that is disciplined, comprehensive, based on intellectual standards, and as a result, well reasoned
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critical thinking indicators
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evidence-based descriptions and behaviors that demonstrate the knowledge, characteristics and skills that promote critical thinking in critical practice
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decision making
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purposeful, goal-directed effort applied in a systematic way to make a choice among alternatives
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evaluate
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measurement of the extent to which the patient has achieved the goals specified in the care plan; care plan is terminated or revised if needed
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expected outcomes
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specific measurable criteria used to evaluate whether a patient goal has been met
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implement
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carry out the plan of care
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intuitive problem solving
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direct understanding of a situation based on a background of experience, knowledge, and skill that makes decisions making possible
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nursing diagnosis
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actual or potential health problem that an independent nursing intervention can prevent and resolve
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Nursing Process
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five step systematic method for giving patient care; assess, diagnose, plan, implement, evaluate
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Plan
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establish patient goals, to prevent, reduce, or resolve the problems identified in the nursing diagnosis and determination of related nursing interventions
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Scientific Problem Solving
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scientific method of problem solving; identification, data collection, hypothesis, plan actions, hypothesis testing, interpret results, evaluate
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standards for critical thinking
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clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate, fair
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trial and error problem solving
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testing solutions until finding one that works
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assessing
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- identify nursing and medical concerns
- determine credibility of info - identify & determine risks for abnormal findings - distinguish relevant from irrelevant data - |
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cue
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significant information that is helpful in making decisions
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emergency assessment
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rapid focused assessment to determine potentially fatal situations
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focused assessment
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conducted to assess a specific problem; pertinent history and body regions
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inference
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the judgement reached about a cue
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initial assessment
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comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgement about patients health status, ability to manage their care, need for nursing, and to develop a care plan
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interview
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planned communication for a specific purpose
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minimum data set
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a standard established by health care institutions that specifies the information that must be collected from every patient
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nursing history
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assessment of the patient by interview to identify the patients health status, strengths, health problems, risks, and need for care
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objective data
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information perceptible by tha senses, can be observed
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observation
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deliberate use of the five senses to gather data
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physical assessment
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systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care
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review of systems ROS
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physical examination of all body systems in a systematic matter as part of the nursing assessment
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subjective data
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information perceived only by the affected person
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time-lapsed assessment
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an assessment to compare a patients data to baseline data that was gathered earlier
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validation
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act of confirming or verifying
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actual nursing diagnosis
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problems validated by the presence of major defining characteristics
four components: label, definition, defining characteristics, and related factors |
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collaborative problems
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actual or potential health problem that may occur from complication of disease, diagnostic studies, or treatment regimen
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data cluster
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grouping of patient data or cues that points to the existence of a patient health problem
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diagnosing
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-creating a list of suspected problems/diagnosis
- ruling out similar problems - naming actual/potential problems and clarifying causes/contributions - determining managment of risk factors - identify resources and areas for health promotion |
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diagnostic error
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failure to detect an actual unhealthy behavior
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health problem
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condition related to health requiring intervention if disease or illness is to be prevented
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medical diagnosis
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statement about a specific disease process using terminology accepted by the medical profession
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possible nursing diagnosis
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statements describing a suspected problem for which additional data is needed to confirm or rule out
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risk nursing diagnosis
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clinical judgements that an individual, family, or community is more vulnerable to develop than others in the same or similar situation
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standard
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acceptable, expected level of performance established by authority, custom, or consent
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syndrome nursing diagnosis
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cluster of actual or risk nursing diagnosis that are predicted to be present because of a certain event or situation
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wellness diagnosis
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clinical judgement about and individual, family, or community in transition from a specific level of wellness to a higher one
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clinical pathways
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case management tools used to communicate the standardized plan of care for a particular group of patients
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computerized plans of nursing care
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care plans developed by software programs that list causes, goals, interventions, nursing/medical diagnosis
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consultation
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process in which two or more individuals with varying degrees of experience deliberate about a problem and it's solution
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criteria
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specified behavior; specifies how a patient must preform a desired behavior
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discharge planning
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systematic process of preparing the patient to leave the health care facility and maintaining continuing care
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expected outcome
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specific, measurable criteria to evaluate whether or not apatient goal has been met
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goal
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an aim or end
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initial planning
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addresses each problem listed in the nursing diagnosis and identifies patient goals and related nursing care
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Kardex care plan
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documentation plan that encompasses:
1. prescriptions for nursing care related to activites of daily living 2. nursing diagnosis, patient goals, nursing orders 3. nursing care related to diagnostic measures and the medical regimen |
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nursing intervention
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treatment based on clinical judgement and knowledge, that a nurse preforms to enhance patient outcomes
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nursing intervention classification
NIC |
comprehensive list of nursing interventions that can be used by nurses in all settings to facilitate identifying appropriate interventions
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ongoing planning
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planning carried out by the nurse who interacts with the patient to keep plan up to date, to resolve health problems, mange risk factors, and promote function
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outcome identification
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observation of the patient to demonstrate the resolution of the problems identified by the nursing diagnosis and general problems list, along with a time frame for accomplishing these outcomes
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patient outcome
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expected conlclusion to a patients health problems
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plan of nursing care
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written guide that directs the efforts of the nursing team
diagnosis, outcomes, and related interventions |
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planning
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-establish priorities
- identify expected outcomes - select nursing intervention - communicate care plan |
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standardized care plans
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prepared plan of care that identifies nursing diagnosis, patient goals, and related nursing orders, common to a specific problem or population
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collaborative interventions
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interdependent nursing actions performed jointly by nurses and other health care personel
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delegation
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transferring of the responsibility of the performance of an activity, while retaining accountability for the outcome
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evidence-based practice
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nursing care provided that is supported by sound scientific rationale
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implementing
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- carry out the care plan
- continue date collection - modify plan as needed - document care |
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nursing interventions
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any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance patient outcomes
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protocols
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written plan that details nursing activities to be executed in certain situations
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standing orders
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document that details the care to be implemented in certain situations, when a doctor is not present; may expand scope of nursing responsibility
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concurrent evaluation
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evaluation of nursing care and patient outcomes while patient is receiving care, patient interviews and chart review to determine whether criteria are met
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evaluating
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- measure how well the patient has achieved desired outcomes
- identify factors contributing to patient's success or failure - modify care plan if needed |
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nursing audit
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method of evaluating the outcomes of nursing care or the process by the which these outcomes are achieved using review of patient records
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outcome evaluation
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evaluation that focuses on measurable changes in the health status of a patient or the end results of nursing care
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peer review
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evaluation at the closest point to the patient and an ongoing tool for professional growth
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Nursing Process
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- assess patient to determine need for nursing care
- determine nursing diagnosis for actual and potential health problems - identify expected outcomes and plan care - implement care - evaluate results |
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Characteristics of Nursing Process
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- pateint cenered
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Nursing Process Characteristics
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patient centered, systematic, dynamic, interpersonal, outcome oriented, universally applicable in nursing situations
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Benefits of Nursing Process
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continuity of care, promotes patient participation, improved quality of care,efficient use of time and resources, expectations and standards of care are met, holds nurses accountable, care is holistic/continuous/systematic
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Sources of patient data
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patient, family, nursing/medical records, consultations, health care team, diagnostic results, relevant literature
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Methods of Data collection
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observation, interview, physical assessment
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Communication Techniques
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paraphrasing, clarifying, focusing, summarizing, open-ended questions
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Nursing Diagnosis 1
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clinical judgement about individual, family or community responses to actual or potential health/life processes
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Nursing Diagnosis 2
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identifications of factors that contribute to or cause health problems
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Nursing Diagnosis 3
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provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
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Nursing Diagnosis 4
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- determined by the nurse
- clinical judgement about patient - human responses to disease or treatment - may change |
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Medical Diagnosis
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- determined by physician
- indicates disease, illness - doesn't change |
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Types of nursing diagnosis
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- actual, risk, possible, syndrome, wellness, collaborative
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Formulating Nursing Dx - actual
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1. Label/Problem
related to 2. Contributing Factors/Etiology as evidenced by/secondary to 3. Signs/Symptoms |
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Formulating Nursing Dx - actual
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1. What's the problem
2. what causes the problem 3. what evidence do you have that you've correctly identified the problem |
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Rules for Nursing Dx
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- don't use medical diagnosis as part of
- follow correct format |
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Example of nursing dx- actual
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1. acute pain
2. tissue trauma 3. sharp right knee pain as expressed by patient |
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Example of nursing dx- risk
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1. risk for injury
2. impaired mobility secondary to arthritis |
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Formulating Nursing Dx - risk
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1. potential problem
2. risk factors 3. no evidence 4. problem does not exist but could if no interventions are done |
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Planning/Outcomes
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- patient-centered
- outcomes or measurable goals - within time constraints - individualized - attainable/realistic/specific - short term and long term expectations |
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Planning/Outcomes 2
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- outcomes always focus on specific patient behaviors or conditions
- prioritized according to Maslow's heirarchy |
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Interventions 1
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- what nurse will do to reach the planning outcomes or goals
- can be direct or indirect care but always focus on patient outcomes |
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Interventions 2
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- care plan/issue/patient specific
- consistent with professional standards of care, protocols, policies, procedures of hospital, and EBP - include relevant patient/family teaching |
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Evaluation 1
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- nurse and patient together measure how well outcomes have been achieved
- goal may be met, partially met, or not met |
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Evaluation 2
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- terminate the plan of care when each expected outcome is achieved
- modify plan of care if needed - continue care plan if more time is needed - data supporting evaluation should be included |
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Decision-Making process model
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DIGEST
- describe situation - identify the problem - get the facts - evaluate the alternatives - select alternative - take action |
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Method of Critical Thinking
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- purpose of thinking
- adequacy of knowledge - potential problems - helpful resources - critique of judgment/decision - focused critical thinking guides |
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How to think critically
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- think independently
- fair minded - intellectually humble - good faith and integrity - curious and persevering - disciplined, creative, confident |